Obamacare 2023 Rates for Howard County

Obamacare > Rates > Missouri > Howard County

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Obamacare is also known as the Affordable Care Act. This page gives you an overview of the rates for individual and family health insurance plans available from , the marketplace for Howard County, MO.

The health insurance rates listed below are for calendar year 2023.

For information on subsidies to make your coverage affordable, you must take one of the following actions:

  • Contact a licensed health insurance agent
  • Complete an application at Healthcare.gov
  • Contact the provider directly

Obamacare Providers, 59 Plans and 2023 Rates for Howard County, Missouri

Below, you’ll find a summary of the 59 plans for Howard County, Missouri and rates for each of these providers.‡ This chart is designed to give you a preview of your health insurance options.

You may also be interested in:

Obamacare Rates and Providers for Other Years

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Howard County Resources

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Anthem Blue Cross and Blue Shield

Local: 1-855-738-6677 | Toll Free: 1-855-738-6677

Toc - Plan #1 Anthem Blue Cross and Blue Shield
Silver

(EPO) Anthem Silver Pathway X 3100 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$3,100 $6,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$488.88
$554.88
$624.79
$873.14
$1,326.82 		$862.87
$928.87
$998.78
$1,247.13 		$1,236.86
$1,302.86
$1,372.77
$1,621.12 		$1,610.85
$1,676.85
$1,746.76
$1,995.11 		$373.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$977.76
$1,109.76
$1,249.58
$1,746.28
$2,653.64 		$1,351.75
$1,483.75
$1,623.57
$2,120.27 		$1,725.74
$1,857.74
$1,997.56
$2,494.26 		$2,099.73
$2,231.73
$2,371.55
$2,868.25 		$373.99
Toc - Plan #2 Anthem Blue Cross and Blue Shield
Expanded Bronze

(EPO) Anthem Bronze Pathway X 6800 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$6,800 $13,600 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$403.91
$458.44
$516.20
$721.38
$1,096.21 		$712.90
$767.43
$825.19
$1,030.37 		$1,021.89
$1,076.42
$1,134.18
$1,339.36 		$1,330.88
$1,385.41
$1,443.17
$1,648.35 		$308.99
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$807.82
$916.88
$1,032.40
$1,442.76
$2,192.42 		$1,116.81
$1,225.87
$1,341.39
$1,751.75 		$1,425.80
$1,534.86
$1,650.38
$2,060.74 		$1,734.79
$1,843.85
$1,959.37
$2,369.73 		$308.99
Toc - Plan #3 Anthem Blue Cross and Blue Shield
Expanded Bronze

(EPO) Anthem Bronze Pathway X 0% for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$7,450 $14,900 Annual Deductible
$7,450 $14,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$402.45
$456.78
$514.33
$718.78
$1,092.25 		$710.32
$764.65
$822.20
$1,026.65 		$1,018.19
$1,072.52
$1,130.07
$1,334.52 		$1,326.06
$1,380.39
$1,437.94
$1,642.39 		$307.87
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$804.90
$913.56
$1,028.66
$1,437.56
$2,184.50 		$1,112.77
$1,221.43
$1,336.53
$1,745.43 		$1,420.64
$1,529.30
$1,644.40
$2,053.30 		$1,728.51
$1,837.17
$1,952.27
$2,361.17 		$307.87
Toc - Plan #4 Anthem Blue Cross and Blue Shield
Expanded Bronze

(EPO) Anthem Bronze Pathway X 20% for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$5,900 $11,800 Annual Deductible
$7,000 $14,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$407.21
$462.18
$520.41
$727.28
$1,105.17 		$718.73
$773.70
$831.93
$1,038.80 		$1,030.25
$1,085.22
$1,143.45
$1,350.32 		$1,341.77
$1,396.74
$1,454.97
$1,661.84 		$311.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$814.42
$924.36
$1,040.82
$1,454.56
$2,210.34 		$1,125.94
$1,235.88
$1,352.34
$1,766.08 		$1,437.46
$1,547.40
$1,663.86
$2,077.60 		$1,748.98
$1,858.92
$1,975.38
$2,389.12 		$311.52
Toc - Plan #5 Anthem Blue Cross and Blue Shield
Silver

(EPO) Anthem Silver Pathway X 3900 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$3,900 $7,800 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$486.41
$552.08
$621.63
$868.73
$1,320.12 		$858.51
$924.18
$993.73
$1,240.83 		$1,230.61
$1,296.28
$1,365.83
$1,612.93 		$1,602.71
$1,668.38
$1,737.93
$1,985.03 		$372.10
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$972.82
$1,104.16
$1,243.26
$1,737.46
$2,640.24 		$1,344.92
$1,476.26
$1,615.36
$2,109.56 		$1,717.02
$1,848.36
$1,987.46
$2,481.66 		$2,089.12
$2,220.46
$2,359.56
$2,853.76 		$372.10
Toc - Plan #6 Anthem Blue Cross and Blue Shield
Silver

(EPO) Anthem Silver Pathway X 3000 for HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$3,000 $6,000 Annual Deductible
$6,450 $12,900 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$487.95
$553.82
$623.60
$871.48
$1,324.30 		$861.23
$927.10
$996.88
$1,244.76 		$1,234.51
$1,300.38
$1,370.16
$1,618.04 		$1,607.79
$1,673.66
$1,743.44
$1,991.32 		$373.28
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$975.90
$1,107.64
$1,247.20
$1,742.96
$2,648.60 		$1,349.18
$1,480.92
$1,620.48
$2,116.24 		$1,722.46
$1,854.20
$1,993.76
$2,489.52 		$2,095.74
$2,227.48
$2,367.04
$2,862.80 		$373.28
Toc - Plan #7 Anthem Blue Cross and Blue Shield
Expanded Bronze

(EPO) Anthem Bronze Pathway X 6500 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$401.08
$455.23
$512.58
$716.33
$1,088.53 		$707.91
$762.06
$819.41
$1,023.16 		$1,014.74
$1,068.89
$1,126.24
$1,329.99 		$1,321.57
$1,375.72
$1,433.07
$1,636.82 		$306.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$802.16
$910.46
$1,025.16
$1,432.66
$2,177.06 		$1,108.99
$1,217.29
$1,331.99
$1,739.49 		$1,415.82
$1,524.12
$1,638.82
$2,046.32 		$1,722.65
$1,830.95
$1,945.65
$2,353.15 		$306.83
Toc - Plan #8 Anthem Blue Cross and Blue Shield
Silver

(EPO) Anthem Silver Pathway X 5400 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$8,300 $16,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$478.16
$542.71
$611.09
$853.99
$1,297.73 		$843.95
$908.50
$976.88
$1,219.78 		$1,209.74
$1,274.29
$1,342.67
$1,585.57 		$1,575.53
$1,640.08
$1,708.46
$1,951.36 		$365.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$956.32
$1,085.42
$1,222.18
$1,707.98
$2,595.46 		$1,322.11
$1,451.21
$1,587.97
$2,073.77 		$1,687.90
$1,817.00
$1,953.76
$2,439.56 		$2,053.69
$2,182.79
$2,319.55
$2,805.35 		$365.79
Toc - Plan #9 Anthem Blue Cross and Blue Shield
Silver

(EPO) Anthem Silver Pathway X 6500 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$6,500 $13,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$475.07
$539.20
$607.14
$848.48
$1,289.34 		$838.50
$902.63
$970.57
$1,211.91 		$1,201.93
$1,266.06
$1,334.00
$1,575.34 		$1,565.36
$1,629.49
$1,697.43
$1,938.77 		$363.43
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$950.14
$1,078.40
$1,214.28
$1,696.96
$2,578.68 		$1,313.57
$1,441.83
$1,577.71
$2,060.39 		$1,677.00
$1,805.26
$1,941.14
$2,423.82 		$2,040.43
$2,168.69
$2,304.57
$2,787.25 		$363.43
Toc - Plan #10 Anthem Blue Cross and Blue Shield
Catastrophic

(EPO) Anthem Catastrophic Pathway X 9100

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$293.41
$333.02
$374.98
$524.03
$796.31 		$517.87
$557.48
$599.44
$748.49 		$742.33
$781.94
$823.90
$972.95 		$966.79
$1,006.40
$1,048.36
$1,197.41 		$224.46
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$586.82
$666.04
$749.96
$1,048.06
$1,592.62 		$811.28
$890.50
$974.42
$1,272.52 		$1,035.74
$1,114.96
$1,198.88
$1,496.98 		$1,260.20
$1,339.42
$1,423.34
$1,721.44 		$224.46
Toc - Plan #11 Anthem Blue Cross and Blue Shield
Expanded Bronze

(EPO) Anthem Bronze Pathway X 4350 ($0 Virtual PCP + $0 Select Drugs + Incentives)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$4,350 $8,700 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$417.35
$473.69
$533.37
$745.39
$1,132.69 		$736.62
$792.96
$852.64
$1,064.66 		$1,055.89
$1,112.23
$1,171.91
$1,383.93 		$1,375.16
$1,431.50
$1,491.18
$1,703.20 		$319.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$834.70
$947.38
$1,066.74
$1,490.78
$2,265.38 		$1,153.97
$1,266.65
$1,386.01
$1,810.05 		$1,473.24
$1,585.92
$1,705.28
$2,129.32 		$1,792.51
$1,905.19
$2,024.55
$2,448.59 		$319.27
Toc - Plan #12 Anthem Blue Cross and Blue Shield
Bronze

(EPO) Anthem Bronze Pathway X 9100/0% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$378.86
$430.01
$484.18
$676.64
$1,028.23 		$668.69
$719.84
$774.01
$966.47 		$958.52
$1,009.67
$1,063.84
$1,256.30 		$1,248.35
$1,299.50
$1,353.67
$1,546.13 		$289.83
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$757.72
$860.02
$968.36
$1,353.28
$2,056.46 		$1,047.55
$1,149.85
$1,258.19
$1,643.11 		$1,337.38
$1,439.68
$1,548.02
$1,932.94 		$1,627.21
$1,729.51
$1,837.85
$2,222.77 		$289.83
Toc - Plan #13 Anthem Blue Cross and Blue Shield
Expanded Bronze

(EPO) Anthem Bronze Pathway X 7500/50% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$415.24
$471.30
$530.68
$741.62
$1,126.96 		$732.90
$788.96
$848.34
$1,059.28 		$1,050.56
$1,106.62
$1,166.00
$1,376.94 		$1,368.22
$1,424.28
$1,483.66
$1,694.60 		$317.66
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$830.48
$942.60
$1,061.36
$1,483.24
$2,253.92 		$1,148.14
$1,260.26
$1,379.02
$1,800.90 		$1,465.80
$1,577.92
$1,696.68
$2,118.56 		$1,783.46
$1,895.58
$2,014.34
$2,436.22 		$317.66
Toc - Plan #14 Anthem Blue Cross and Blue Shield
Silver

(EPO) Anthem Silver Pathway X 5800/40% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$473.93
$537.91
$605.68
$846.44
$1,286.25 		$836.49
$900.47
$968.24
$1,209.00 		$1,199.05
$1,263.03
$1,330.80
$1,571.56 		$1,561.61
$1,625.59
$1,693.36
$1,934.12 		$362.56
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$947.86
$1,075.82
$1,211.36
$1,692.88
$2,572.50 		$1,310.42
$1,438.38
$1,573.92
$2,055.44 		$1,672.98
$1,800.94
$1,936.48
$2,418.00 		$2,035.54
$2,163.50
$2,299.04
$2,780.56 		$362.56
Toc - Plan #15 Anthem Blue Cross and Blue Shield
Gold

(EPO) Anthem Gold Pathway X 2000/25% Standard

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-738-6677

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$727.82
$826.08
$930.15
$1,299.89
$1,975.30 		$1,284.60
$1,382.86
$1,486.93
$1,856.67 		$1,841.38
$1,939.64
$2,043.71
$2,413.45 		$2,398.16
$2,496.42
$2,600.49
$2,970.23 		$556.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,455.64
$1,652.16
$1,860.30
$2,599.78
$3,950.60 		$2,012.42
$2,208.94
$2,417.08
$3,156.56 		$2,569.20
$2,765.72
$2,973.86
$3,713.34 		$3,125.98
$3,322.50
$3,530.64
$4,270.12 		$556.78

ADVERTISEMENT

Medica

Local: 1-888-592-8211 | Toll Free: 1-888-592-8211 | TTY: 1-800-676-3777
Toc - Plan #16 Medica
Expanded Bronze

(EPO) Medica with MU Health Care Bronze HSA ($0 Virtual Care after Deductible with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$495.55
$562.44
$633.30
$885.03
$1,344.89 		$874.64
$941.53
$1,012.39
$1,264.12 		$1,253.73
$1,320.62
$1,391.48
$1,643.21 		$1,632.82
$1,699.71
$1,770.57
$2,022.30 		$379.09
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$991.10
$1,124.88
$1,266.60
$1,770.06
$2,689.78 		$1,370.19
$1,503.97
$1,645.69
$2,149.15 		$1,749.28
$1,883.06
$2,024.78
$2,528.24 		$2,128.37
$2,262.15
$2,403.87
$2,907.33 		$379.09
Toc - Plan #17 Medica
Catastrophic

(EPO) Medica with MU Health Care Catastrophic ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$292.28
$331.72
$373.52
$521.99
$793.21 		$515.86
$555.30
$597.10
$745.57 		$739.44
$778.88
$820.68
$969.15 		$963.02
$1,002.46
$1,044.26
$1,192.73 		$223.58
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$584.56
$663.44
$747.04
$1,043.98
$1,586.42 		$808.14
$887.02
$970.62
$1,267.56 		$1,031.72
$1,110.60
$1,194.20
$1,491.14 		$1,255.30
$1,334.18
$1,417.78
$1,714.72 		$223.58
Toc - Plan #18 Medica
Silver

(EPO) Medica with MU Health Care Silver Share ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$577.89
$655.90
$738.54
$1,032.10
$1,568.38 		$1,019.97
$1,097.98
$1,180.62
$1,474.18 		$1,462.05
$1,540.06
$1,622.70
$1,916.26 		$1,904.13
$1,982.14
$2,064.78
$2,358.34 		$442.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,155.78
$1,311.80
$1,477.08
$2,064.20
$3,136.76 		$1,597.86
$1,753.88
$1,919.16
$2,506.28 		$2,039.94
$2,195.96
$2,361.24
$2,948.36 		$2,482.02
$2,638.04
$2,803.32
$3,390.44 		$442.08
Toc - Plan #19 Medica
Expanded Bronze

(EPO) Medica with MU Health Care Bronze Share Plus ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$2,500 $5,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$421.88
$478.82
$539.15
$753.45
$1,144.95 		$744.61
$801.55
$861.88
$1,076.18 		$1,067.34
$1,124.28
$1,184.61
$1,398.91 		$1,390.07
$1,447.01
$1,507.34
$1,721.64 		$322.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$843.76
$957.64
$1,078.30
$1,506.90
$2,289.90 		$1,166.49
$1,280.37
$1,401.03
$1,829.63 		$1,489.22
$1,603.10
$1,723.76
$2,152.36 		$1,811.95
$1,925.83
$2,046.49
$2,475.09 		$322.73
Toc - Plan #20 Medica
Expanded Bronze

(EPO) Medica with MU Health Care Bronze Copay $0 PCP ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$409.88
$465.20
$523.81
$732.03
$1,112.39 		$723.43
$778.75
$837.36
$1,045.58 		$1,036.98
$1,092.30
$1,150.91
$1,359.13 		$1,350.53
$1,405.85
$1,464.46
$1,672.68 		$313.55
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$819.76
$930.40
$1,047.62
$1,464.06
$2,224.78 		$1,133.31
$1,243.95
$1,361.17
$1,777.61 		$1,446.86
$1,557.50
$1,674.72
$2,091.16 		$1,760.41
$1,871.05
$1,988.27
$2,404.71 		$313.55
Toc - Plan #21 Medica
Gold

(EPO) Medica with MU Health Care Gold Copay $0 PCP ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$1,000 $2,000 Annual Deductible
$8,350 $16,700 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$611.58
$694.13
$781.58
$1,092.26
$1,659.79 		$1,079.43
$1,161.98
$1,249.43
$1,560.11 		$1,547.28
$1,629.83
$1,717.28
$2,027.96 		$2,015.13
$2,097.68
$2,185.13
$2,495.81 		$467.85
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,223.16
$1,388.26
$1,563.16
$2,184.52
$3,319.58 		$1,691.01
$1,856.11
$2,031.01
$2,652.37 		$2,158.86
$2,323.96
$2,498.86
$3,120.22 		$2,626.71
$2,791.81
$2,966.71
$3,588.07 		$467.85
Toc - Plan #22 Medica
Expanded Bronze

(EPO) Medica with MU Health Care Bronze Premier ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$1,500 $3,000 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$411.34
$466.86
$525.68
$734.64
$1,116.36 		$726.01
$781.53
$840.35
$1,049.31 		$1,040.68
$1,096.20
$1,155.02
$1,363.98 		$1,355.35
$1,410.87
$1,469.69
$1,678.65 		$314.67
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$822.68
$933.72
$1,051.36
$1,469.28
$2,232.72 		$1,137.35
$1,248.39
$1,366.03
$1,783.95 		$1,452.02
$1,563.06
$1,680.70
$2,098.62 		$1,766.69
$1,877.73
$1,995.37
$2,413.29 		$314.67
Toc - Plan #23 Medica
Gold

(EPO) Medica with MU Health Care Gold Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$581.67
$660.18
$743.36
$1,038.84
$1,578.62 		$1,026.64
$1,105.15
$1,188.33
$1,483.81 		$1,471.61
$1,550.12
$1,633.30
$1,928.78 		$1,916.58
$1,995.09
$2,078.27
$2,373.75 		$444.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,163.34
$1,320.36
$1,486.72
$2,077.68
$3,157.24 		$1,608.31
$1,765.33
$1,931.69
$2,522.65 		$2,053.28
$2,210.30
$2,376.66
$2,967.62 		$2,498.25
$2,655.27
$2,821.63
$3,412.59 		$444.97
Toc - Plan #24 Medica
Silver

(EPO) Medica with MU Health Care Silver Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$553.39
$628.09
$707.22
$988.34
$1,501.88 		$976.73
$1,051.43
$1,130.56
$1,411.68 		$1,400.07
$1,474.77
$1,553.90
$1,835.02 		$1,823.41
$1,898.11
$1,977.24
$2,258.36 		$423.34
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,106.78
$1,256.18
$1,414.44
$1,976.68
$3,003.76 		$1,530.12
$1,679.52
$1,837.78
$2,400.02 		$1,953.46
$2,102.86
$2,261.12
$2,823.36 		$2,376.80
$2,526.20
$2,684.46
$3,246.70 		$423.34
Toc - Plan #25 Medica
Bronze

(EPO) Medica with MU Health Care Bronze Standard ($0 Virtual Care with Designated Providers)

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-888-592-8211

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$394.05
$447.24
$503.59
$703.76
$1,069.43 		$695.49
$748.68
$805.03
$1,005.20 		$996.93
$1,050.12
$1,106.47
$1,306.64 		$1,298.37
$1,351.56
$1,407.91
$1,608.08 		$301.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$788.10
$894.48
$1,007.18
$1,407.52
$2,138.86 		$1,089.54
$1,195.92
$1,308.62
$1,708.96 		$1,390.98
$1,497.36
$1,610.06
$2,010.40 		$1,692.42
$1,798.80
$1,911.50
$2,311.84 		$301.44

ADVERTISEMENT

Ambetter from Home State Health

Local: 1-855-650-3789 | Toll Free: 1-855-650-3789 | TTY: 1-855-650-3789
Toc - Plan #26 Ambetter from Home State Health
Bronze

(EPO) Clear Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$413.76
$469.61
$528.77
$738.96
$1,122.92 		$730.28
$786.13
$845.29
$1,055.48 		$1,046.80
$1,102.65
$1,161.81
$1,372.00 		$1,363.32
$1,419.17
$1,478.33
$1,688.52 		$316.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$827.52
$939.22
$1,057.54
$1,477.92
$2,245.84 		$1,144.04
$1,255.74
$1,374.06
$1,794.44 		$1,460.56
$1,572.26
$1,690.58
$2,110.96 		$1,777.08
$1,888.78
$2,007.10
$2,427.48 		$316.52
Toc - Plan #27 Ambetter from Home State Health
Silver

(EPO) Premier Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 Annual Deductible
$7,750 $15,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$479.22
$543.91
$612.43
$855.87
$1,300.58 		$845.82
$910.51
$979.03
$1,222.47 		$1,212.42
$1,277.11
$1,345.63
$1,589.07 		$1,579.02
$1,643.71
$1,712.23
$1,955.67 		$366.60
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$958.44
$1,087.82
$1,224.86
$1,711.74
$2,601.16 		$1,325.04
$1,454.42
$1,591.46
$2,078.34 		$1,691.64
$1,821.02
$1,958.06
$2,444.94 		$2,058.24
$2,187.62
$2,324.66
$2,811.54 		$366.60
Toc - Plan #28 Ambetter from Home State Health
Silver

(EPO) Complete Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$477.45
$541.89
$610.17
$852.71
$1,295.77 		$842.69
$907.13
$975.41
$1,217.95 		$1,207.93
$1,272.37
$1,340.65
$1,583.19 		$1,573.17
$1,637.61
$1,705.89
$1,948.43 		$365.24
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$954.90
$1,083.78
$1,220.34
$1,705.42
$2,591.54 		$1,320.14
$1,449.02
$1,585.58
$2,070.66 		$1,685.38
$1,814.26
$1,950.82
$2,435.90 		$2,050.62
$2,179.50
$2,316.06
$2,801.14 		$365.24
Toc - Plan #29 Ambetter from Home State Health
Gold

(EPO) Complete Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$7,700 $15,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$593.66
$673.79
$758.68
$1,060.25
$1,611.16 		$1,047.80
$1,127.93
$1,212.82
$1,514.39 		$1,501.94
$1,582.07
$1,666.96
$1,968.53 		$1,956.08
$2,036.21
$2,121.10
$2,422.67 		$454.14
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,187.32
$1,347.58
$1,517.36
$2,120.50
$3,222.32 		$1,641.46
$1,801.72
$1,971.50
$2,574.64 		$2,095.60
$2,255.86
$2,425.64
$3,028.78 		$2,549.74
$2,710.00
$2,879.78
$3,482.92 		$454.14
Toc - Plan #30 Ambetter from Home State Health
Expanded Bronze

(EPO) Everyday Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$448.03
$508.50
$572.56
$800.16
$1,215.91 		$790.76
$851.23
$915.29
$1,142.89 		$1,133.49
$1,193.96
$1,258.02
$1,485.62 		$1,476.22
$1,536.69
$1,600.75
$1,828.35 		$342.73
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$896.06
$1,017.00
$1,145.12
$1,600.32
$2,431.82 		$1,238.79
$1,359.73
$1,487.85
$1,943.05 		$1,581.52
$1,702.46
$1,830.58
$2,285.78 		$1,924.25
$2,045.19
$2,173.31
$2,628.51 		$342.73
Toc - Plan #31 Ambetter from Home State Health
Expanded Bronze

(EPO) Choice Bronze HSA

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$454.78
$516.17
$581.20
$812.22
$1,234.25 		$802.68
$864.07
$929.10
$1,160.12 		$1,150.58
$1,211.97
$1,277.00
$1,508.02 		$1,498.48
$1,559.87
$1,624.90
$1,855.92 		$347.90
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$909.56
$1,032.34
$1,162.40
$1,624.44
$2,468.50 		$1,257.46
$1,380.24
$1,510.30
$1,972.34 		$1,605.36
$1,728.14
$1,858.20
$2,320.24 		$1,953.26
$2,076.04
$2,206.10
$2,668.14 		$347.90
Toc - Plan #32 Ambetter from Home State Health
Expanded Bronze

(EPO) Elite Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$501.79
$569.52
$641.28
$896.18
$1,361.84 		$885.65
$953.38
$1,025.14
$1,280.04 		$1,269.51
$1,337.24
$1,409.00
$1,663.90 		$1,653.37
$1,721.10
$1,792.86
$2,047.76 		$383.86
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,003.58
$1,139.04
$1,282.56
$1,792.36
$2,723.68 		$1,387.44
$1,522.90
$1,666.42
$2,176.22 		$1,771.30
$1,906.76
$2,050.28
$2,560.08 		$2,155.16
$2,290.62
$2,434.14
$2,943.94 		$383.86
Toc - Plan #33 Ambetter from Home State Health
Silver

(EPO) Clear Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$5,400 $10,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$462.02
$524.38
$590.45
$825.15
$1,253.89 		$815.46
$877.82
$943.89
$1,178.59 		$1,168.90
$1,231.26
$1,297.33
$1,532.03 		$1,522.34
$1,584.70
$1,650.77
$1,885.47 		$353.44
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$924.04
$1,048.76
$1,180.90
$1,650.30
$2,507.78 		$1,277.48
$1,402.20
$1,534.34
$2,003.74 		$1,630.92
$1,755.64
$1,887.78
$2,357.18 		$1,984.36
$2,109.08
$2,241.22
$2,710.62 		$353.44
Toc - Plan #34 Ambetter from Home State Health
Silver

(EPO) Focused Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$470.69
$534.22
$601.53
$840.64
$1,277.43 		$830.76
$894.29
$961.60
$1,200.71 		$1,190.83
$1,254.36
$1,321.67
$1,560.78 		$1,550.90
$1,614.43
$1,681.74
$1,920.85 		$360.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$941.38
$1,068.44
$1,203.06
$1,681.28
$2,554.86 		$1,301.45
$1,428.51
$1,563.13
$2,041.35 		$1,661.52
$1,788.58
$1,923.20
$2,401.42 		$2,021.59
$2,148.65
$2,283.27
$2,761.49 		$360.07
Toc - Plan #35 Ambetter from Home State Health
Gold

(EPO) Everyday Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$568.59
$645.34
$726.65
$1,015.49
$1,543.14 		$1,003.56
$1,080.31
$1,161.62
$1,450.46 		$1,438.53
$1,515.28
$1,596.59
$1,885.43 		$1,873.50
$1,950.25
$2,031.56
$2,320.40 		$434.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,137.18
$1,290.68
$1,453.30
$2,030.98
$3,086.28 		$1,572.15
$1,725.65
$1,888.27
$2,465.95 		$2,007.12
$2,160.62
$2,323.24
$2,900.92 		$2,442.09
$2,595.59
$2,758.21
$3,335.89 		$434.97
Toc - Plan #36 Ambetter from Home State Health
Gold

(EPO) Clear Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$560.16
$635.77
$715.87
$1,000.43
$1,520.25 		$988.68
$1,064.29
$1,144.39
$1,428.95 		$1,417.20
$1,492.81
$1,572.91
$1,857.47 		$1,845.72
$1,921.33
$2,001.43
$2,285.99 		$428.52
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,120.32
$1,271.54
$1,431.74
$2,000.86
$3,040.50 		$1,548.84
$1,700.06
$1,860.26
$2,429.38 		$1,977.36
$2,128.58
$2,288.78
$2,857.90 		$2,405.88
$2,557.10
$2,717.30
$3,286.42 		$428.52
Toc - Plan #37 Ambetter from Home State Health
Gold

(EPO) Elite Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,300 $10,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$649.77
$737.48
$830.40
$1,160.48
$1,763.46 		$1,146.84
$1,234.55
$1,327.47
$1,657.55 		$1,643.91
$1,731.62
$1,824.54
$2,154.62 		$2,140.98
$2,228.69
$2,321.61
$2,651.69 		$497.07
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,299.54
$1,474.96
$1,660.80
$2,320.96
$3,526.92 		$1,796.61
$1,972.03
$2,157.87
$2,818.03 		$2,293.68
$2,469.10
$2,654.94
$3,315.10 		$2,790.75
$2,966.17
$3,152.01
$3,812.17 		$497.07
Toc - Plan #38 Ambetter from Home State Health
Bronze

(EPO) CMS Standard Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$9,100 $18,200 Annual Deductible
$9,100 $18,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$394.45
$447.69
$504.09
$704.47
$1,070.51 		$696.20
$749.44
$805.84
$1,006.22 		$997.95
$1,051.19
$1,107.59
$1,307.97 		$1,299.70
$1,352.94
$1,409.34
$1,609.72 		$301.75
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$788.90
$895.38
$1,008.18
$1,408.94
$2,141.02 		$1,090.65
$1,197.13
$1,309.93
$1,710.69 		$1,392.40
$1,498.88
$1,611.68
$2,012.44 		$1,694.15
$1,800.63
$1,913.43
$2,314.19 		$301.75
Toc - Plan #39 Ambetter from Home State Health
Expanded Bronze

(EPO) CMS Standard Expanded Bronze

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$433.94
$492.51
$554.56
$774.99
$1,177.68 		$765.89
$824.46
$886.51
$1,106.94 		$1,097.84
$1,156.41
$1,218.46
$1,438.89 		$1,429.79
$1,488.36
$1,550.41
$1,770.84 		$331.95
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$867.88
$985.02
$1,109.12
$1,549.98
$2,355.36 		$1,199.83
$1,316.97
$1,441.07
$1,881.93 		$1,531.78
$1,648.92
$1,773.02
$2,213.88 		$1,863.73
$1,980.87
$2,104.97
$2,545.83 		$331.95
Toc - Plan #40 Ambetter from Home State Health
Silver

(EPO) CMS Standard Silver

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$461.16
$523.40
$589.34
$823.61
$1,251.55 		$813.94
$876.18
$942.12
$1,176.39 		$1,166.72
$1,228.96
$1,294.90
$1,529.17 		$1,519.50
$1,581.74
$1,647.68
$1,881.95 		$352.78
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$922.32
$1,046.80
$1,178.68
$1,647.22
$2,503.10 		$1,275.10
$1,399.58
$1,531.46
$2,000.00 		$1,627.88
$1,752.36
$1,884.24
$2,352.78 		$1,980.66
$2,105.14
$2,237.02
$2,705.56 		$352.78
Toc - Plan #41 Ambetter from Home State Health
Gold

(EPO) CMS Standard Gold

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$560.54
$636.21
$716.36
$1,001.11
$1,521.29 		$989.35
$1,065.02
$1,145.17
$1,429.92 		$1,418.16
$1,493.83
$1,573.98
$1,858.73 		$1,846.97
$1,922.64
$2,002.79
$2,287.54 		$428.81
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,121.08
$1,272.42
$1,432.72
$2,002.22
$3,042.58 		$1,549.89
$1,701.23
$1,861.53
$2,431.03 		$1,978.70
$2,130.04
$2,290.34
$2,859.84 		$2,407.51
$2,558.85
$2,719.15
$3,288.65 		$428.81
Toc - Plan #42 Ambetter from Home State Health
Expanded Bronze

(EPO) Clear Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$8,600 $17,200 Annual Deductible
$8,600 $17,200 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$427.23
$484.90
$545.99
$763.02
$1,159.48 		$754.05
$811.72
$872.81
$1,089.84 		$1,080.87
$1,138.54
$1,199.63
$1,416.66 		$1,407.69
$1,465.36
$1,526.45
$1,743.48 		$326.82
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$854.46
$969.80
$1,091.98
$1,526.04
$2,318.96 		$1,181.28
$1,296.62
$1,418.80
$1,852.86 		$1,508.10
$1,623.44
$1,745.62
$2,179.68 		$1,834.92
$1,950.26
$2,072.44
$2,506.50 		$326.82
Toc - Plan #43 Ambetter from Home State Health
Expanded Bronze

(EPO) Everyday Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$8,300 $16,600 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$462.61
$525.05
$591.20
$826.21
$1,255.50 		$816.50
$878.94
$945.09
$1,180.10 		$1,170.39
$1,232.83
$1,298.98
$1,533.99 		$1,524.28
$1,586.72
$1,652.87
$1,887.88 		$353.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$925.22
$1,050.10
$1,182.40
$1,652.42
$2,511.00 		$1,279.11
$1,403.99
$1,536.29
$2,006.31 		$1,633.00
$1,757.88
$1,890.18
$2,360.20 		$1,986.89
$2,111.77
$2,244.07
$2,714.09 		$353.89
Toc - Plan #44 Ambetter from Home State Health
Gold

(EPO) Complete Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$1,450 $2,900 Annual Deductible
$7,700 $15,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$612.98
$695.73
$783.38
$1,094.77
$1,663.61 		$1,081.91
$1,164.66
$1,252.31
$1,563.70 		$1,550.84
$1,633.59
$1,721.24
$2,032.63 		$2,019.77
$2,102.52
$2,190.17
$2,501.56 		$468.93
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,225.96
$1,391.46
$1,566.76
$2,189.54
$3,327.22 		$1,694.89
$1,860.39
$2,035.69
$2,658.47 		$2,163.82
$2,329.32
$2,504.62
$3,127.40 		$2,632.75
$2,798.25
$2,973.55
$3,596.33 		$468.93
Toc - Plan #45 Ambetter from Home State Health
Silver

(EPO) Complete Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$6,000 $12,000 Annual Deductible
$8,500 $17,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$492.99
$559.54
$630.03
$880.47
$1,337.95 		$870.12
$936.67
$1,007.16
$1,257.60 		$1,247.25
$1,313.80
$1,384.29
$1,634.73 		$1,624.38
$1,690.93
$1,761.42
$2,011.86 		$377.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$985.98
$1,119.08
$1,260.06
$1,760.94
$2,675.90 		$1,363.11
$1,496.21
$1,637.19
$2,138.07 		$1,740.24
$1,873.34
$2,014.32
$2,515.20 		$2,117.37
$2,250.47
$2,391.45
$2,892.33 		$377.13
Toc - Plan #46 Ambetter from Home State Health
Silver

(EPO) Premier Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$7,750 $15,500 Annual Deductible
$7,750 $15,500 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$494.82
$561.61
$632.37
$883.74
$1,342.92 		$873.35
$940.14
$1,010.90
$1,262.27 		$1,251.88
$1,318.67
$1,389.43
$1,640.80 		$1,630.41
$1,697.20
$1,767.96
$2,019.33 		$378.53
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$989.64
$1,123.22
$1,264.74
$1,767.48
$2,685.84 		$1,368.17
$1,501.75
$1,643.27
$2,146.01 		$1,746.70
$1,880.28
$2,021.80
$2,524.54 		$2,125.23
$2,258.81
$2,400.33
$2,903.07 		$378.53
Toc - Plan #47 Ambetter from Home State Health
Expanded Bronze

(EPO) Choice Bronze HSA + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$6,900 $13,800 Annual Deductible
$6,900 $13,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$469.59
$532.97
$600.12
$838.67
$1,274.43 		$828.82
$892.20
$959.35
$1,197.90 		$1,188.05
$1,251.43
$1,318.58
$1,557.13 		$1,547.28
$1,610.66
$1,677.81
$1,916.36 		$359.23
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$939.18
$1,065.94
$1,200.24
$1,677.34
$2,548.86 		$1,298.41
$1,425.17
$1,559.47
$2,036.57 		$1,657.64
$1,784.40
$1,918.70
$2,395.80 		$2,016.87
$2,143.63
$2,277.93
$2,755.03 		$359.23
Toc - Plan #48 Ambetter from Home State Health
Expanded Bronze

(EPO) Elite Bronze + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$518.13
$588.06
$662.16
$925.36
$1,406.17 		$914.49
$984.42
$1,058.52
$1,321.72 		$1,310.85
$1,380.78
$1,454.88
$1,718.08 		$1,707.21
$1,777.14
$1,851.24
$2,114.44 		$396.36
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,036.26
$1,176.12
$1,324.32
$1,850.72
$2,812.34 		$1,432.62
$1,572.48
$1,720.68
$2,247.08 		$1,828.98
$1,968.84
$2,117.04
$2,643.44 		$2,225.34
$2,365.20
$2,513.40
$3,039.80 		$396.36
Toc - Plan #49 Ambetter from Home State Health
Silver

(EPO) Focused Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$6,100 $12,200 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$486.02
$551.62
$621.12
$868.01
$1,319.02 		$857.81
$923.41
$992.91
$1,239.80 		$1,229.60
$1,295.20
$1,364.70
$1,611.59 		$1,601.39
$1,666.99
$1,736.49
$1,983.38 		$371.79
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$972.04
$1,103.24
$1,242.24
$1,736.02
$2,638.04 		$1,343.83
$1,475.03
$1,614.03
$2,107.81 		$1,715.62
$1,846.82
$1,985.82
$2,479.60 		$2,087.41
$2,218.61
$2,357.61
$2,851.39 		$371.79
Toc - Plan #50 Ambetter from Home State Health
Gold

(EPO) Everyday Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$750 $1,500 Annual Deductible
$7,500 $15,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$587.11
$666.35
$750.31
$1,048.55
$1,593.38 		$1,036.24
$1,115.48
$1,199.44
$1,497.68 		$1,485.37
$1,564.61
$1,648.57
$1,946.81 		$1,934.50
$2,013.74
$2,097.70
$2,395.94 		$449.13
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,174.22
$1,332.70
$1,500.62
$2,097.10
$3,186.76 		$1,623.35
$1,781.83
$1,949.75
$2,546.23 		$2,072.48
$2,230.96
$2,398.88
$2,995.36 		$2,521.61
$2,680.09
$2,848.01
$3,444.49 		$449.13
Toc - Plan #51 Ambetter from Home State Health
Silver

(EPO) Clear Silver + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$5,400 $10,800 Annual Deductible
$5,400 $10,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$477.06
$541.45
$609.67
$852.01
$1,294.71 		$842.00
$906.39
$974.61
$1,216.95 		$1,206.94
$1,271.33
$1,339.55
$1,581.89 		$1,571.88
$1,636.27
$1,704.49
$1,946.83 		$364.94
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$954.12
$1,082.90
$1,219.34
$1,704.02
$2,589.42 		$1,319.06
$1,447.84
$1,584.28
$2,068.96 		$1,684.00
$1,812.78
$1,949.22
$2,433.90 		$2,048.94
$2,177.72
$2,314.16
$2,798.84 		$364.94
Toc - Plan #52 Ambetter from Home State Health
Gold

(EPO) Clear Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$578.40
$656.47
$739.18
$1,033.00
$1,569.74 		$1,020.87
$1,098.94
$1,181.65
$1,475.47 		$1,463.34
$1,541.41
$1,624.12
$1,917.94 		$1,905.81
$1,983.88
$2,066.59
$2,360.41 		$442.47
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,156.80
$1,312.94
$1,478.36
$2,066.00
$3,139.48 		$1,599.27
$1,755.41
$1,920.83
$2,508.47 		$2,041.74
$2,197.88
$2,363.30
$2,950.94 		$2,484.21
$2,640.35
$2,805.77
$3,393.41 		$442.47
Toc - Plan #53 Ambetter from Home State Health
Gold

(EPO) Elite Gold + Vision + Adult Dental

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$0 $0 Annual Deductible
$5,300 $10,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$670.93
$761.49
$857.43
$1,198.26
$1,820.87 		$1,184.18
$1,274.74
$1,370.68
$1,711.51 		$1,697.43
$1,787.99
$1,883.93
$2,224.76 		$2,210.68
$2,301.24
$2,397.18
$2,738.01 		$513.25
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,341.86
$1,522.98
$1,714.86
$2,396.52
$3,641.74 		$1,855.11
$2,036.23
$2,228.11
$2,909.77 		$2,368.36
$2,549.48
$2,741.36
$3,423.02 		$2,881.61
$3,062.73
$3,254.61
$3,936.27 		$513.25
Toc - Plan #54 Ambetter from Home State Health
Expanded Bronze

(EPO) Ambetter Virtual Access Bronze - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$7,000 $14,000 Annual Deductible
$8,550 $17,100 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$435.66
$494.46
$556.76
$778.07
$1,182.36 		$768.93
$827.73
$890.03
$1,111.34 		$1,102.20
$1,161.00
$1,223.30
$1,444.61 		$1,435.47
$1,494.27
$1,556.57
$1,777.88 		$333.27
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$871.32
$988.92
$1,113.52
$1,556.14
$2,364.72 		$1,204.59
$1,322.19
$1,446.79
$1,889.41 		$1,537.86
$1,655.46
$1,780.06
$2,222.68 		$1,871.13
$1,988.73
$2,113.33
$2,555.95 		$333.27
Toc - Plan #55 Ambetter from Home State Health
Silver

(EPO) Ambetter Virtual Access Silver - Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$5,700 $11,400 Annual Deductible
$7,400 $14,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$460.25
$522.37
$588.18
$821.98
$1,249.08 		$812.33
$874.45
$940.26
$1,174.06 		$1,164.41
$1,226.53
$1,292.34
$1,526.14 		$1,516.49
$1,578.61
$1,644.42
$1,878.22 		$352.08
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$920.50
$1,044.74
$1,176.36
$1,643.96
$2,498.16 		$1,272.58
$1,396.82
$1,528.44
$1,996.04 		$1,624.66
$1,748.90
$1,880.52
$2,348.12 		$1,976.74
$2,100.98
$2,232.60
$2,700.20 		$352.08
Toc - Plan #56 Ambetter from Home State Health
Gold

(EPO) Ambetter Virtual Access Gold- Virtual PCP selection required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$900 $1,800 Annual Deductible
$8,300 $16,600 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$572.96
$650.29
$732.22
$1,023.28
$1,554.97 		$1,011.26
$1,088.59
$1,170.52
$1,461.58 		$1,449.56
$1,526.89
$1,608.82
$1,899.88 		$1,887.86
$1,965.19
$2,047.12
$2,338.18 		$438.30
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,145.92
$1,300.58
$1,464.44
$2,046.56
$3,109.94 		$1,584.22
$1,738.88
$1,902.74
$2,484.86 		$2,022.52
$2,177.18
$2,341.04
$2,923.16 		$2,460.82
$2,615.48
$2,779.34
$3,361.46 		$438.30
Toc - Plan #57 Ambetter from Home State Health
Expanded Bronze

(EPO) CMS Standard Virtual Access Basic Bronze ? Virtual PCP Selection Required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$7,500 $15,000 Annual Deductible
$9,000 $18,000 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$451.28
$512.20
$576.73
$805.98
$1,224.76 		$796.50
$857.42
$921.95
$1,151.20 		$1,141.72
$1,202.64
$1,267.17
$1,496.42 		$1,486.94
$1,547.86
$1,612.39
$1,841.64 		$345.22
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$902.56
$1,024.40
$1,153.46
$1,611.96
$2,449.52 		$1,247.78
$1,369.62
$1,498.68
$1,957.18 		$1,593.00
$1,714.84
$1,843.90
$2,302.40 		$1,938.22
$2,060.06
$2,189.12
$2,647.62 		$345.22
Toc - Plan #58 Ambetter from Home State Health
Silver

(EPO) CMS Standard Virtual Access Basic Silver ? Virtual PCP Selection Required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$5,800 $11,600 Annual Deductible
$8,900 $17,800 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$479.61
$544.34
$612.92
$856.56
$1,301.62 		$846.50
$911.23
$979.81
$1,223.45 		$1,213.39
$1,278.12
$1,346.70
$1,590.34 		$1,580.28
$1,645.01
$1,713.59
$1,957.23 		$366.89
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$959.22
$1,088.68
$1,225.84
$1,713.12
$2,603.24 		$1,326.11
$1,455.57
$1,592.73
$2,080.01 		$1,693.00
$1,822.46
$1,959.62
$2,446.90 		$2,059.89
$2,189.35
$2,326.51
$2,813.79 		$366.89
Toc - Plan #59 Ambetter from Home State Health
Gold

(EPO) CMS Standard Virtual Access Basic Gold ? Virtual PCP Selection Required

Benefits & Coverage Plan Brochure Provider Directory
Customer Service Phone: 1-855-650-3789

Annual Out of Pocket Expenses:

Individual Family
$2,000 $4,000 Annual Deductible
$8,700 $17,400 Maximum Out of Pocket Per Year

Monthly Premiums:

[show premiums]
Age Individual
 Individual
1 Child
 Individual
2 Children
 Individual
3+ Children
 Child
0-14
21
30
40
50
60 		$582.97
$661.66
$745.02
$1,041.17
$1,582.16 		$1,028.94
$1,107.63
$1,190.99
$1,487.14 		$1,474.91
$1,553.60
$1,636.96
$1,933.11 		$1,920.88
$1,999.57
$2,082.93
$2,379.08 		$445.97
Age Couple
Couple
1 Child
 Couple
2 Chidren
 Couple
3+ Children
 Child
0-14
21
30
40
50
60 		$1,165.94
$1,323.32
$1,490.04
$2,082.34
$3,164.32 		$1,611.91
$1,769.29
$1,936.01
$2,528.31 		$2,057.88
$2,215.26
$2,381.98
$2,974.28 		$2,503.85
$2,661.23
$2,827.95
$3,420.25 		$445.97

‡Source: HealthCare.gov has released sample rates for all counties in the 36 states served by HealthCare.gov. We have integrated that data into our tables and provide you that information for Howard County here.

Howard County is in “Rating Area 5” of Missouri.

Currently, there are 59 plans offered in Rating Area 5.

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2023 Obamacare Plans for Howard County, MO

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